1487646030 NPI number — MARK EDMUND THOMPSON D.O.

Table of content: MARK EDMUND THOMPSON D.O. (NPI 1487646030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487646030 NPI number — MARK EDMUND THOMPSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
MARK
Provider Middle Name:
EDMUND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487646030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4520 W US HIGHWAY 90
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32055-8341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-755-0601
Provider Business Mailing Address Fax Number:
352-755-0602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4520 W US HIGHWAY 90
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32055-8341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-755-0601
Provider Business Practice Location Address Fax Number:
352-755-0602
Provider Enumeration Date:
08/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  OS10194 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X , with the licence number: OS10194 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 310302 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 279300800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0825156 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: PTAN AG644E . This is a "LINKED TO GROUP PTAN IE881A EFFECTIVE 08/01/2015" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 02484 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117165400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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